The growing number of patients with chronic kidney disease (CKD) is a public health challenge. Several interventions have been proven to be effective in improving outcomes for patients with CKD, but many patients do not receive these therapies. The gap between advances in knowledge of how to treat CKD and implementation of optimal care is especially large for members of certain ethnic and racial minorities and underserved populations. The main goal of this proposal is to improve the care of all patients with CKD and to develop strategies that may prove to be particularly effective in high risk underserved populations. Our main teaching hospital, Parkland Health and Hospital Systems (PHHS), cares for the underserved in Dallas County and serves a predominantly African-American and Hispanic population. PHHS has a network of primary care clinics distributed throughout the community and designated as Medical Homes. PHHS has a fully operational IT-enabled program, the Parkland Intelligent e- Coordination and Evaluation System (PIECES), that facilitates harnessing the electronic medical record to implement, coordinate and monitor evidence-based interventions in our patient population. The main hypothesis of this proposal is that a new model of joint primary care-nephrology care will improve clinical management of risk factors for progression of CKD and CV complications in patients with chronic kidney disease. We also propose that the application of a novel health information technology platform will allow earlier detection of CKD in African-American and Hispanic patient populations and facilitate CKD care and preparation for renal replacement therapy. The first specific aim is to improve detection of CKD in the high risk predominantly minority population served at PHHS. The second specific aim is to implement interventions proven to slow the progression of CKD and treat associated conditions. The third specific aim is to prepare patients for optimal initiation o renal replacement therapy including preparation for transplantation and if dialysis is needed, timely modality selection, access placement and avoiding temporary central venous catheters. Successful application of this collaborative primary care/nephrology model of care which incorporates new health information technology has the potential to improve the care not only for minority patients in our institution for all CKD patients in the United States. PUBLIC HEALTH RELEVANCE: Chronic kidney disease (CKD) is a common medical problem that leads to higher mortality, hospitalizations, and costs. Many patients do not receive treatments proven to help slow the progression of kidney disease and its complications. This study is directed to improving the care of CKD patients especially for those in minority populations that are at the highest risk.